P16 as a molecular biomarker of cervical adenocarcinoma

doi:10.1016/j.ajog.2003.09.038

American Journal of Obstetrics and Gynecology

Volume 190, Issue 3, March 2004, Pages 668-673

https://doi.org/10.1016/j.ajog.2003.09.038 Get rights and content

Abstract

Objective

Cervical adenocarcinomas are increasing in incidence each year. The aim of this study was to identify a molecular biomarker to improve early detection.

Study design

Fifty-five in situ and invasive cervical adenocarcinomas were compared with 5 normal endocervical controls by immunohistochemical analysis of p16, p21, p27, cyclin D1, cyclin E, p53, and Ki-67. Expression was scored from 0 to 8 by using an automated imaging system. Western blotting and polymerase chain reaction-based human papillomavirus (HPV) testing were performed on 16 of the invasive cases having fresh-frozen tissue.

Results

P16 exhibited a higher mean expression score for in situ (7.4; P<.0001) and invasive cervical adenocarcinoma (6.6; P<.0001) versus controls (2.0). A cutoff p16 expression score of 5 had a sensitivity of 94.5% and a specificity of 100%. Western blotting confirmed p16 protein expression. Fourteen (88%) of 16 invasive cervical adenocarcinomas were HPV-positive.

Conclusion

P16 is a putative molecular biomarker of cervical adenocarcinoma. Overexpression appears to primarily reflect HPV-induced cell cycle dysregulation.

Section snippets

Patient selection

Institutional Review Board (IRB) approval was obtained to perform a computerized search of all patients diagnosed with in situ and invasive cervical adenocarcinoma from 1994 to 2002 at the University of Texas Southwestern Medical Center.

Tissue samples

Surgical pathology reports were retrieved and hematoxylin and eosin (H&E) slides were reviewed to select blocks for tumor sections. The histologic diagnosis of in situ or invasive cervical adenocarcinoma was confirmed by a gynecologic pathologist coauthor

Immunohistochemistry

A higher mean p16 expression score was observed for in situ (7.4; P<.0001) and invasive cervical adenocarcinoma (6.6; P<.0001), compared with controls (2.0; Table II; Fig 1, Fig 2). P16 expression at a cutoff immmunohistochemical expression score of 5 had a sensitivity of 94.5% and a specificity of 100% in both in situ and invasive cervical adenocarcinoma specimens (area under the ROC curve: 0.924).

There was no difference between p21, p27, or p53 gene expressions comparing in situ or invasive

Comment

P16 is a putative molecular biomarker that consistently discriminates cervical adenocarcinoma from benign endocervix. In this study, p16 expression at a cutoff immmunohistochemical expression score of 5 had a sensitivity of 94.5% and a specificity of 100% among the in situ and invasive cervical adenocarcinoma specimens. Diffusely positive p16 overexpression has been recently reported by Negri et al¹⁵ in all 8 adenocarcinoma in situ cases and 17 (94%) of 18 invasive cervical adenocarcinomas

References (25)

H.O Smith et al.
The rising incidence of adenocarcinoma relative to squamous cell carcinoma of the uterine cervix in the United States—a 24-year population-based study
Gynecol Oncol
(2000)
B Clarke et al.
Cell cycle aberrations in the pathogenesis of squamous cell carcinoma of the uterine cervix
Gynecol Oncol
(2001)
L Riethdorf et al.
Human papillomaviruses, expression of p16, and early endocervical glandular neoplasia
Hum Pathol
(2002)
E.C Pirog et al.
Prevalence of human papillomavirus DNA in different histological subtypes of cervical adenocarcinoma
Am J Pathol
(2000)
J.S Park et al.
Physical status and expression of HPV genes in cervical cancers
Gynecol Oncol
(1997)
J.W Kim et al.
Absence of p15INK4B and p16INK4A gene alterations in primary cervical tissues and cell lines with human papillomavirus infection
Gynecol Oncol
(1998)
A.P Vizcaino et al.
International trends in the incidence of cervical cancer: I, adenocarcinoma and adenosquamous cell carcinomas
Int J Cancer
(1998)
K.R Lee et al.
Early invasive adenocarcinoma of the cervix
Cancer
(2000)
J.O Schorge et al.
ThinPrep detection of cervical and endometrial adenocarcinoma: a retrospective cohort study
Cancer
(2002)
H Bai et al.
ThinPrep Pap test promotes detection of glandular lesions of the endocervix
Diagn Cytopathol
(2000)

W.G McCluggage

Endocervical glandular lesions: controversial aspects and ancillary techniques

J Clin Pathol

(2003)

R.I Cameron et al.

Immunohistochemical staining with MIB1, bcl-2, and p16 assists in the distinction of cervical glandular intraepithelial neoplasia from tubo-endometrial metaplasia, endometriosis and microglandular hyperplasia

Histopathology

(2002)

Cited by (49)

Immunohistochemical markers Ki67 and P16 help predict prognosis in locally advanced cervical cancer
2024, European Journal of Obstetrics and Gynecology and Reproductive Biology
To investigate the relationship between Ki-67 and P16 expression levels after neoadjuvant chemotherapy, and the clinicopathological characteristics and prognosis of patients with locally advanced cervical cancer.
Patients with FIGO 2009 stage IB2 or IIA2 cervical cancer, who underwent neoadjuvant chemotherapy combined with radical hysterectomy at the First Affiliated Hospital of Chongqing Medical University between January 2015 and December 2019, were identified retrospectively to correlate postoperative Ki-67 and P16 expression levels with clinicopathological factors. The optimal threshold for predicting recurrence was analysed using receiver operating characteristic (ROC) curves for the Ki-67 index, and univariate and multi-factorial Cox regression analysis were used to investigate the association between clinicpathological features including Ki-67 and P16 and recurrence-free survival.
In total, 334 patients were included after screening. The cut-off value of Ki-67 for determining recurrence was 67.5 % according to the ROC curve. On multi-factorial Cox analysis, lymphatic vascular space (p = 0.003) and Ki-67 index (p = 0.005) were shown to increase the risk of recurrence, and were independent prognostic factors for recurrence, while the expression of P16 was not significantly associated with the risk of recurrence (p = 0.097, odds ratio = 0.319). Patients with cervical cancer in the high Ki-67 expression group (Ki-67 ≥ 67.5 %) had lower recurrence-free survival and overall survival than patients in the low Ki-67 expression group (Ki-67 < 67.5 %) (p = 0.001 and 0.036, respectively).
The expression levels of Ki-67 and P16 after neoadjuvant chemotherapy for locally advanced cervical cancer correlated with tumour differentiation. High expression of Ki-67 (Ki-67 ≥ 67.5 %) may indicate poorer recurrence-free survival and overall survival.
Diagnostic value of p16 and Ki-67 expression in cervical glandular intraepithelial disease: A review
2023, Annals of Diagnostic Pathology
Citation Excerpt :
In 2011 the study of Negri et al. [2] was based on the percentage of stained cells, while in his oldest study he used the criteria of qualitative analysis of staining (diffuse, focal or negative for p16). Schorge et al. [10] and Jr. et al. [4] used the same integrated score where the intensity of staining was evaluated together with the percentage of stained cells. Liang et al. [8] also used an integrated score where he combined the intensity and percentage of stained cells but with a different punctuation.
Cervical adenocarcinoma has been increasing in frequency, particularly among young women. Its diagnosis still presents many challenges. In addition to the difficulty in accessing the lesion, the lack of well-established criterias for cytological and histological diagnosis, and colposcopic images that are often not very clear, there are many benign situations that mimic glandular diseases. Immunohistochemistry has been used to aid this diagnosis. The purpose of this review is to evaluate the data available in the literature related to the use of p16 and Ki-67 as an auxiliary tool in the diagnosis of glandular disease.
Original articles were searched in the PUBMED/MEDLINE, EMBASE, SCOPUS and BVS using different combinations of keywords and descriptors.
Of the 83 initial articles, 10 were selected. The criterias used for immunohistochemical interpretation showed many differences. The studies compared benign pathologies to malignant pathologies and some used panels with different immunomarkers while others used only p16. P16 showed an intense staining pattern in malignant pathologies, despite some studies have shown a negative pattern in adenocarcinoma. This can be explained by the histological subtype, not always related to HPV. Some studies have shown immunopositivity for p16 in normal tissues, tubal metaplasia and cervical endometriosis, but the staining pattern was never intense, as in malignant tissues. Ki-67 showed a more intense staining in AIS and adenocarcinoma tissues and was also present in normal tissues, mainly in tubal metaplasia and cervical endometriosis.
Biomarkers have proved to be important tools in aiding the diagnosis of glandular lesions, either alone or in panels. Standardization in the interpretation of immunochemistry is required.
Evaluation of p16<sup>INK4a</sup> immunostaining for the detection of high-grade changes in cervical cytology
2015, Pathology
Since its introduction in Australia in 2007, the human papillo-mavirus (HPV) vaccine has led to a markedly lower prevalence of vaccine targeted HPV genotype infections as well as HPV disease including genital warts and histologically confirmed high-grade (HG) cervical abnormalities. To increase the ability to identify abnormal cells in lower prevalence, adjunct markers can be incorporated to improve the sensitivity and specificity of cytology test. One such marker is p16^INK4a(p16), which is detectable in cells expressing the E7 oncogene encoded by high-risk HPVs (HR-HPV). In this study, the sensitivity and specificity of p16 immunostaining in detection of underlying HG lesions was evaluated in a cohort of 454 women undergoing surgical treatment for biopsy proven cervical dysplasia. Overall, p16 positive cells were detected in 321 (71%) of cytology preparations evaluated. Comparison of p16 staining on cytological preprations to histology diagnosis available on 212 patients, showed 26 (54%), 41 (78%) and 80 (90%) of cytology preparations to be p16 positive in women with CIN1, CIN2 and CIN3, respectively (p < 0.005). HPV16 and 18 were the most prevalent genotypes in HG lesions and were highly correlated with p16 staining. p16 staining provides an additional marker which can assist in better detecting underlying HG lesion in cytology smears with low disease prevalence.
The diagnostic value of immunohistochemistry in cervical lesions
2012, Revista Espanola de Patologia
En los últimos años han proliferado las técnicas inmunohistoquímicas que se postulan como útiles en el estudio de las lesiones del cérvix uterino. Por ello, resulta necesario una revisión de las evidencias existentes y el establecimiento de paneles científicamente contrastados y útiles en la práctica diaria.
Se han analizado los trabajos más relevantes de la literatura sobre el uso de la inmunohistoquímica en el estudio de lesiones de cérvix y se ha realizado una revisión crítica de su utilidad diagnóstica y de su valor pronóstico.
Aunque diferentes anticuerpos como Ki67 o ProExC han demostrado utilidad en el diagnóstico de las lesiones escamosas premalignas y su diferenciación de las lesiones reactivas, p16^INK4a demuestra la mayor sensibilidad y especificidad. La utilización de p16^INK4a facilita la detección de lesiones pequeñas o de difícil diagnóstico y disminuye de modo significativo la variabilidad inter e intraobservador. Por el contrario, las lesiones glandulares presentan un diagnóstico diferencial mucho más complejo en el que se requiere un panel inmunohistoquímico más amplio que incluya, además de p16^INK4a, CEA, receptores de estrógenos y progesterona, vimentina y bcl-2, presentando, además, una especificidad mucho menor.
Mientras que la inmunohistoquímica aporta una información diagnóstica de gran fiabilidad y utilidad en la evaluación y el manejo de las lesiones escamosas, su utilidad en el diagnóstico de lesiones glandulares es menos específica y está limitada a la confirmación de algunas patologías específicas y a una ayuda en el diagnóstico diferencial entre lesiones benignas y malignas.
The availability of many different immunohistochemical techniques for the diagnosis of cervical lesions over the last decade calls for a practical review of their usefulness.
The most relevant reports on the use of immunohistochemical stains in the study of cervical lesions have been analyzed and their diagnostic and prognostic value has been reviewed.
Although a number of antibodies such as Ki67 o ProExC have been shown to be helpful in the diagnosis of squamous intraepithelial lesions and their differentiation from reactive lesions, p16^INK4a has shown the highest sensitivity and specificity, is useful in the detection of small lesions and significantly reduces the inter- and intra-observer variability. However, the diagnosis of glandular lesions is much more complex, requiring a wide immunohistochemical panel, which includes p16^INK4a, CEA, oestrogen and progesterone receptors, vimentin and bcl-2, but with only low specificity.
Whereas immunohistochemistry provides useful and reliable diagnostic information in the evaluation of squamous lesions, its application in the diagnosis of glandular lesions is much less specific and is limited to the confirmation of certain tumours and the differential diagnosis of malignant and benign lesions.
Immunocytology
2011, Diagnostic Immunohistochemistry
Value of p16<sup>INK4a</sup> as a marker of progression/regression in cervical intraepithelial neoplasia grade 1
2009, American Journal of Obstetrics and Gynecology
Citation Excerpt :
p16INK4a overexpression indicates interference of the viral oncoproteins with cellular proteins involved in the cell-cycle regulation,10-12 and it is involved in the carcinogenic process induced by HR-HPV. In keeping with this, immunohistochemical overexpression of p16INK4a has been shown to unambiguously identify truly premalignant and malignant cells in the uterine cervix from both squamous and glandular origin.13,20-22 The close relationship between overexpression of p16INK4a and HR-HPV-related premalignant and malignant lesions has also been shown in other settings, such as the vulva,23,24 penis,25 anus,26 tonsil,27 and rinosinusal cavities.28
The objective of this study was to evaluate the usefulness of p16^INK4a staining to classify cervical intraepithelial neoplasia grade 1 according to its progression/regression risk.
Patients with a histologic diagnosis of cervical intraepithelial neoplasia grade 1 were prospectively recruited (n = 138). Simultaneous detection of high-risk human papillomaviruses and p16^INK4a evaluation were performed. Follow-up was conducted every 6 months by cytology and colposcopy and annually by high-risk human papillomavirus testing, for at least 12 months (mean, 29.0). Progression was defined as a histologic diagnosis of cervical intraepithelial neoplasia grades 2-3, regression as a negative cytology and high-risk human papillomaviruses, and persistence as a cytologic result of low-grade squamous intraepithelial lesions and/or a positive test for high-risk human papillomaviruses.
Progression was observed in 14 women (10.1%), 66 (47.6%) regressed, and 58 (42.0%) had a persistent disease. p16^INK4a was positive in 77 (55.8%) initial biopsy specimens. Progression to cervical intraepithelial neoplasia grades 2-3 was identified in 14 of 77 (18.2%) women with positive and none of 61 (0.00%) women with negative p16^INK4a immunostaining (P < .001).
p16^INK4a negative cervical intraepithelial neoplasia grade 1 lesions rarely progress and may benefit from a less intensive follow-up.

View all citing articles on Scopus

^☆: This study was supported by the 2002 Berlex Scholar Award in Basic Science Research awarded to J.O.S.

View full text

P16 as a molecular biomarker of cervical adenocarcinoma☆

Abstract

Objective

Study design

Results

Conclusion

Section snippets

Patient selection

Tissue samples

Immunohistochemistry

Comment

Gynecol Oncol

Gynecol Oncol

Hum Pathol

Am J Pathol

Gynecol Oncol

Gynecol Oncol

International trends in the incidence of cervical cancer: I, adenocarcinoma and adenosquamous cell carcinomas

Int J Cancer

Early invasive adenocarcinoma of the cervix

Cancer

ThinPrep detection of cervical and endometrial adenocarcinoma: a retrospective cohort study

Cancer

ThinPrep Pap test promotes detection of glandular lesions of the endocervix

Diagn Cytopathol

Endocervical glandular lesions: controversial aspects and ancillary techniques

J Clin Pathol

Immunohistochemical staining with MIB1, bcl-2, and p16 assists in the distinction of cervical glandular intraepithelial neoplasia from tubo-endometrial metaplasia, endometriosis and microglandular hyperplasia

Histopathology